The Current Encounter pertains to the present or on-going interaction that the patient is undergoing with respect to the Medical Records Module users. You can watch the video or follow the steps below:
Video
STEPS
Go to EMR > Queues.
Select the patient in line and accommodate the patient.
For solo practice clinics, you can directly go to the Patients list > Search patient > Create Encounter.
Vital Signs and other health indicators:
Select a field.
Type the necessary details.
For each section, you can add the date of when the record was made, delete an entry, and add a new entry.
Chief complaint:
Type the necessary details on the text field.
History of Present Illness:
Type the necessary details on the text field.
Review of Systems:
Mark the patient's current status per system.
Mark "None" if there are no abnormalities.
Mark "Positive" if there are significant abnormalities.
Provide remarks for systems marked with "Positive."
Physical Exam:
Mark the patient's current status per organ.
Mark "None" if there are no abnormalities.
Mark "Positive" if there are significant abnormalities.
Provide remarks for organs marked with "Positive."
Input necessary details.
Adjust the dot on the line scale to select the patient's Level of Consciousness and Pain Assessment.
Impression:
Type your initial impression about the patient’s medical condition on the text field.
ICD-10 Diagnosis:
Select the ICD10 Code or the International Statistical Classification of Diseases. The list provided by the system is in its 10th revision issued by the World Health Organization. This will help the users, especially doctors to classify and code their diagnosis.
Type on the text field for the medical condition diagnosis of the patient.
Finalizing the records:
Click
Save Records. It's always available on the bottom right of the page anytime you need to save changes.Click
Bill Encounterto charge your patient at the end of the visit. Payment may be administered by your staff at the end of the patient's journey.